Patient Form

PATIENT REGISTRATION FORM

1. Concealing any medical information may result in the termination of the registration form.
2. Our clinic cannot guarantee acceptance of your registration form, as our doctor(s) are limited to the number of patients he/she can have. We do our best to try and accommodate as many patients as possible.
3. Please answer ALL of the questions even if the answer is "NO"

(pharmacy on-site, if needed)
Please bring a list of medications with you. If you do not have a list, your pharmacist can provide you with one.

Please note that our office will not request old records until you have met with a physician. If your previous records are required a "Release of Information Form" will need to be signed and forwarded to your previous physician.

Please note it could take several months before you are notified of an appointment time. Wait time can increase due to patient demand.

By Clicking Submit you also agree to the "Clinic Policies" & "No Show or Late Arrival and Late Cancellation Fee Policy"
But filling up the form below and clicking submit you agree that Richmond Row Health Centre Physician(s) and staff members to leave detailed messages as follows: